This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text The Summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

Schottenfeld R.S., Chawarski M.C., Mazlan M.Lancet: 2008, 371, p. 2192–2200.Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Schottenfeld at Richard.schottenfeld@yale.edu. You could also try this alternative source.

This unique randomised trial tested what would happen if detoxified opiate addicts were then maintained on a substitute drug, on an opiate-blocking medication, or simply counselled. The results led to the introduction of methadone prescribing programmes in Malaysia.

Summary As a follow-on treatment after opiate detoxification, this study compared the efficacy of the opiate-blocking medication naltrexone, the opiate substitute buprenorphine, or no treatment other than the drug counselling all patients received. In Malaysia at the time naltrexone was the main long-term pharmacotherapy and maintenance substitute prescribing was not permitted.

For the authors their findings showed the efficacy of maintenance treatment with buprenorphine in sustaining abstinence, delaying time to resumption of heroin use and relapse, and retaining patients in treatment, lending support to the widespread dissemination of maintenance treatment with buprenorphine as an effective public health approach to heroin dependence.

Though this is the verdict from among the range of options on offer in the study, long-acting forms of naltrexone which last weeks or months might have tipped the balance in favour of abstinence-based therapy, and seamless entry in to (to the patient) acceptable forms of residential rehabilitation or intensive day care might have raised outcomes to the point where the choice of medication was less decisive. In both cases, the caveat is that compared to substitute prescribing, fewer patients are prepared to accept or can access these options, and in the case of residential rehabilitation, the costs per year of heroin use averted are likely to be considerably greater.

The main issue with the study from a UK perspective is its applicability to a country where these are not the only options available, and where even if they were, patients would be expected to be allocated to them on an individual basis in the light of what seems best for that individual. However, there are parallels. As in the featured study, in the UK (and elsewhere) failure to complete detoxification or post-detoxification relapse are the norm, long-acting naltrexone formulations have yet to be licensed and made widely available, and residential rehabilitation remains in short supply. The relevance of the study could be heightened if (as strongly advocated by some political advisers) substitute prescribing is de-emphasised in favour of abstinence-based approaches, especially if the need for economies forces these to take the form of naltrexone or counselling rather than intensive, extensive and expensive psychosocial rehabilitation.

The implications of the study are supported by other studies of detoxification, oral naltrexone and substitute prescribing, though no other study has within itself compared these options. As commentators on the study put it, this wider research base indicates that "The preferred oral pharmacological treatment for opioid dependence should be agonist maintenance with either methadone or buprenorphine." This verdict carefully limited itself to "pharmacological" treatments and to
"oral"
Or in the case of buprenorphine, sublingual.
medications, leaving out more intensive or improved psychosocial approaches or long-acting implanted or injected medications.

In Australia, where polarised opinions favoured substitute prescribing or rejected this in favour of naltrexone, the federal parliament reacted by conducting a review of their respective advantages in the Australian context. The conclusion was that both had their place, but that place was much greater for substitute prescribing. Oral naltrexone was seen as a niche option for the minority of opioid-dependent individuals capable of remaining compliant with the treatment, but for most it had been consistently been linked with high rates of non-compliance, a greater risk of death and reduced likelihood of long-term success. In contrast, methadone and other opioid substitution treatments were seen as widely applicable treatments acknowledged as effective in reducing opioid dependence and associated health and social problems.

Thanks for their comments on this entry in draft to Brian Kidd of Tayside Drug Problems Service and University of Dundee Medical School, and John Witton of the National Addiction Centre in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.